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Question 1
Correct
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A 50-year-old woman diagnosed with non-Hodgkin's Lymphoma is about to be started on the CHOP regimen (cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisolone). Her pre-chemotherapy blood investigations show:
Hb: 11.8 g/dl
Platelets: 423 x 109/l
WBC: 11.2 x 109/l
Na+: 143 mmol/l
K+: 3.9 mmol/l
Urea: 6.2 mmol/l
Creatinine: 78 μmol/l
Uric acid: 0.45 mmol/l
Ciprofloxacin is prescribed in addition to the CHOP regimen to reduce the risk of neutropenic sepsis. Which of the following drugs should be added to lower the risk of other complications?Your Answer: Allopurinol
Explanation: -
This question is part of the following fields:
- Haematology & Oncology
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Question 2
Incorrect
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Which one of the following is a contraindication to the use of a triptan in the management of migraine?
Your Answer: A history of epilepsy
Correct Answer: A history of ischaemic heart disease
Explanation:A history of ischaemic heart disease in a contraindication for prescribing triptans because they act by constricting cerebral and also coronary vessels, increasing the risk of stroke.
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This question is part of the following fields:
- Nervous System
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Question 3
Correct
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A 77-year-old female who is a known to have COPD and metastatic lung cancer is admitted with increasing shortness of breath. Following discussion with her family, it is decided to withdraw active treatment including fluids and antibiotics as the admission likely represents a terminal event. Two days after admission, she becomes agitated and restless.
What is the most appropriate management for her agitation and confusion?Your Answer: Subcutaneous midazolam
Explanation:Generally, underlying causes of confusion need to be looked for and treated as appropriate, for example, hypercalcaemia, infection, urinary retention, and medication. If specific treatments fail, the following may be tried:
1. First choice: haloperidol
2. Other options: chlorpromazine, levomepromazineIn the terminal phase of the illness, agitation or restlessness is best treated with midazolam.
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This question is part of the following fields:
- Haematology & Oncology
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Question 4
Correct
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A 50-year-old man is referred with impotence. He has a history of angina, hypertension and type 2 diabetes.
Which one of the following drugs that he takes is a contraindication to him being able to receive sildenafil?Your Answer: Isosorbide mononitrate
Explanation:Sildenafil administration to patients who are using organic nitrates, either regularly and/or intermittently, in any form is contraindicated.
Organic nitrates and nitric oxide (NO) donors exert their therapeutic effects on blood pressure and vascular smooth muscle by the same mechanism as endogenous NO via increasing cGMP concentrations. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 5
Correct
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A 20-year-old male was admitted with a right sided pneumothorax. A chest drain was inserted just below the 4th rib in the midclavicular line. What is the structure at risk of damage during the above procedure?
Your Answer: Intercostal artery
Explanation:From the given answers, the most suitable answer is the intercostal artery. However the most vulnerable structure is the intercostal nerve, then intercostal artery and finally intercostal vein.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 6
Incorrect
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A 50-year-old woman with lung cancer develops deep vein thrombosis (DVT). She is reviewed in the hospital clinic and started on low-molecular-weight heparin (LMWH).
Which of the following should be the most appropriate treatment plan?Your Answer: Switch to warfarin, continue for 6 months
Correct Answer: Continue on LMWH for 6 months
Explanation:Patients with active cancer are at a continuous risk of having venous thromboembolism (VTE), such as DVT. Therefore, a six-month course of an anticoagulant such as LMWH is recommended. LMWH is the drug of choice since its side effects can be reversed and it can be stopped easily in case of a cancer-related bleed, for example, massive haemoptysis in a patient with lung cancer.
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This question is part of the following fields:
- Haematology & Oncology
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Question 7
Correct
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A 32-year-old male has recently had a splenectomy following a motorcycle accident. He is up to date with all vaccinations which were offered as part of his childhood vaccination scheme. It is July. Which of the following vaccinations does he require in the first instance?
Your Answer: Pneumococcus, meningococcus type B and C, Haemophilus type B
Explanation:Acquired asplenia or hyposlenia can occur following splenectomy. Hyposplenism is used to describe reduced (‘hypo-‘) splenic functioning and is associated with increased risk of sepsis from polysaccharide encapsulated bacteria. In particular, patients are at risk from Streptococcus pneumoniae, Haemophilus influenzae, and meningococcus. The risk is elevated as much as 350-fold.
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This question is part of the following fields:
- Infectious Diseases
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Question 8
Correct
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Which of the following features occurs very less frequently with drug induced lupus?
Your Answer: Glomerulonephritis
Explanation:Drug induced lupus typically presents with pulmonary involvement and no renal or neurological involvement. Hence glomerulonephritis would be highly unlikely in this case. Rash and arthralgias are classic presentations. Pleurisy can be present as pulmonary involvement may occur with DILE.
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This question is part of the following fields:
- Musculoskeletal System
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Question 9
Incorrect
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Which of the following is the drug of choice for the treatment of Chlamydia trachomatis infection during pregnancy?
Your Answer: Clindamycin
Correct Answer: Amoxicillin
Explanation:Tetracycline is not recommended in pregnancy because of the risk to fetal development (bones, teeth!). Metronidazole in pregnancy: currently not thought to be an increased risk in pregnancy; however this is not effective against chlamydia. Amoxicillin is shown to be an adequate treatment for chlamydia, so this is the correct answer.
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This question is part of the following fields:
- Infectious Diseases
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Question 10
Correct
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A 60-year-old male has complained of a recent onset of postural syncope, impotence, diarrhoea, and profuse sweating. He also has diabetes. In this patient, what is the most likely cause of syncope?
Your Answer: Autonomic neuropathy
Explanation:Due to the symptoms, a diabetic autonomic neuropathy should be a suspect as a cause for the syncope. Unless associated with atrial fibrillation, mitral regurgitation is not usually expected to cause syncope. PAF can sometimes present with palpitations and a feeling of light-headedness followed by syncope, but is not always the case.
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This question is part of the following fields:
- Cardiovascular System
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Question 11
Correct
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Which of the following conditions is not linked to hyperuricemia?
Your Answer: Osteoarthritis
Explanation:Hyperuricemia is an elevated uric acid level in the blood. The normal upper limit is 6.8mg/dL, and anything over 7 mg/dL is considered saturated, and symptoms can occur. Causes of hyperuricemia can be classified into three functional types:
1. Increased production of uric acid – Purine rich diet, Tumour lysis syndrome, HGPRT deficiency (Lesch-Nyhan and Kelley-Seegmiller syndromes), Increased PRPP synthetase activity and Polycythaemia
2. Decreased excretion of uric acid – Renal impairment, Metabolic syndrome, Drugs (diuretics, low-dose aspirin, cyclosporin, tacrolimus, pyrazinamide, ethambutol, levodopa, nicotinic acid), Acidosis, Pre-eclampsia and eclampsia, Hypothyroidism and hyperparathyroidism, Sarcoidosis, Familial juvenile gouty nephropathy, Chronic lead intoxication, Trisomy 21
3. Idiopathic and mixed type – Alcohol, Exercise, Glucose-6-phosphatase deficiency, Aldolase B deficiency -
This question is part of the following fields:
- Musculoskeletal System
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Question 12
Incorrect
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A 60-year-old man with atrial fibrillation (AF) who is on warfarin and is awaiting tooth extraction. Recent INR was 2.7 and his target INR was 2.0-3.0. Which of the following is the most appropriate management?
Your Answer: Check INR 72 hours before procedure, proceed if INR < 2.5
Correct Answer:
Explanation:The latest reserches say that simple tooth extraction in patients on warfarin treatment can be performed safely without high risk of bleeding, providing that the INR is equal to or less than 3.5 on the day of extraction. A close follow-up and monitoring of patients taking warfarin is mandatory after dental extraction.
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This question is part of the following fields:
- Cardiovascular System
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Question 13
Correct
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A 22-year-old male has had complex tics since childhood. He repeatedly bends his knees and rubs his nose. He is prone to loud vocalisations, sometimes including swear-words. A diagnosis of Gilles de la Tourette syndrome has been made. Which of the following is the best treatment option?
Your Answer: Risperidone
Explanation:Gilles de la Tourette syndrome is the most severe and rare of the tic syndromes, consisting of multiple tics involving both motor actions and vocalisation. Onset is usually in childhood. Symptoms include utterance of obscenities (coprolalia); echolalia (repetition of another person’s spoken words) and palilalia (involuntary repetition of words, phrases, or sentences).
The underlying cause is unknown, with no particular imaging or standard histopathological abnormalities having been identified. The EEG shows non-specific abnormalities in about half of patients. However, more recent immunocytochemical studies have suggested altered dopamine uptake in the striatal system.
Risperidone is an effective therapeutic option without the effects associated with chlorpromazine and haloperidol. -
This question is part of the following fields:
- Nervous System
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Question 14
Correct
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A study is developed to assess a new anti-hypertensive drug and two groups of patients are randomly chosen. The first group takes an established anti-hypertensive drug for 3 months and the second group receives the new drug, again for 3 months. To assess the efficacy of the new drug, blood pressure is measured before and after taking the drug in both groups of patients. After a period of 1 month off medication, the groups swap medication and blood pressure is measured again, finally the difference in blood pressure after receiving each drug is calculated. Which of the following significance tests would you apply to assess the results of the study?
Your Answer: Student's paired t-test
Explanation:A t test is a type of statistical test that is used to compare the means of two groups. It is one of the most widely used statistical hypothesis tests in pain studies. There are two types of statistical inferences: parametric and nonparametric methods. Parametric methods refer to a statistical technique in which one defines the probability distribution of probability variables and makes inferences about the parameters of the distribution. In cases in which the probability distribution cannot be defined, nonparametric methods are employed. T tests are a type of parametric method; they can be used when the samples satisfy the conditions of normality, equal variance, and independence. In this case the data is parametric, and they belong to the same patients, so a paired t test should be used.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 15
Correct
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You are working as a junior doctor in a medical ward when the pharmacist approaches you and informs you that Mr. Henry is documented as allergic to penicillin but you have prescribed him amoxicillin. The patient has received 3 doses without any reaction. The pharmacist has assured you he will not tell anyone about this incident. Which of the following is the most appropriate step now?
Your Answer: Inform the patient of your mistake
Explanation:The patient should be informed about the mistake. The antibiotic should also be changed and the incident should be documented. Thank the pharmacist for his courteous behaviour but do not encourage his attempt to cover up the matter.
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This question is part of the following fields:
- Ethical & Legal
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Question 16
Correct
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A 50-year-old woman is referred to the outpatient clinic with a 6-month history of diarrhoea. She has had intermittent loose normal-coloured stools 2-3 times a day. She also has up to 10 hot flushes a day but thinks she is entering menopause; her GP has recently started her on hormone replacement therapy.
15 years ago she had a normal colonoscopy after presenting with abdominal pain and intermittent constipation. She has asthma controlled by inhalers, hypertension controlled by ACE inhibitors and hypothyroidism controlled by thyroxine. She smoked 10 cigarettes a day for the last 30 years and drinks alcohol about 14 units/week.
On examination, she looks hot and flushed. She is afebrile. Her pulse is regular 92 bpm and her BP is 164/82 mmHg. Her respirator rate is 20 breaths/min at rest and she sounds quite wheezy. A widespread polyphonic expiratory wheeze can be heard on chest auscultation.
Her abdomen is soft. Her liver is enlarged 4 cm below the right costal margin but not-tender.
Results of blood tests show:
Na 140 mmol/l
K 4.8 mmol/l
Glucose 9.8 mmol/l
Albumin 41 g/l
ALT 94 U/l
ALP 61 U/l
Bilirubin 18 mmol/l
Ca 2.47 mmol/l
WCC 10.1 × 109/l
Hb 12.2 g/dl
MCV 90.5 fl
Platelets 234 × 109 /l
PT 13 s
Chest X-ray is normal.
Ultrasound of the liver shows an enlarged liver containing three ill-defined mass lesions in the right lobe.
What is the most likely diagnosis?Your Answer: Carcinoid syndrome
Explanation:Carcinoid tumours are of neuroendocrine origin and derived from primitive stem cells in the gut wall, especially the appendix. They can be seen in other organs, including the lungs, mediastinum, thymus, liver, bile ducts, pancreas, bronchus, ovaries, prostate, and kidneys. While carcinoid tumours tend to grow slowly, they have the potential to metastasise.
Signs and symptoms seen in larger tumours may include the following:
– Periodic abdominal pain: Most common presentation for a small intestinal carcinoid; often associated with malignant carcinoid syndrome.
– Cutaneous flushing: Early and frequent (94%) symptom; typically affects head and neck.
– Diarrhoea and malabsorption (84%): Watery, frothy, or bulky stools, gastrointestinal (GI) bleed or steatorrhea; may or may not be associated with abdominal pain, flushing, and cramps.
– Cardiac manifestations (60%): Valvular heart lesions, fibrosis of the endocardium; may lead to heart failure with tachycardia and hypertension.
– Wheezing or asthma-like syndrome (25%): Due to bronchial constriction; some tremors are relatively indolent and result in chronic symptoms such as cough and dyspnoea.
– Pellagra with scale-like skin lesions, diarrhoea and mental disturbances.
– Carcinoid crisis can be the most serious symptom of the carcinoid tumours and life-threatening. It can occur suddenly or after stress, including chemotherapy and anaesthesia. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 17
Incorrect
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What is the most appropriate next step if a consultant is nominated at a directorate meeting to undertake the next clinical audit?
Your Answer: Identify standards
Correct Answer: Needs assessment
Explanation:Clinical audit is defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. The first step has to be initial assessment and identifying the issues.
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This question is part of the following fields:
- Ethical & Legal
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Question 18
Correct
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A 36-year-old lady presented with increased bowel motions, palpitations, heat intolerance and loss of weight. She is also tachycardiac. The investigation of choice in this case would be?
Your Answer: Thyroid function test
Explanation:Hyperthyroidism is characterised by heat intolerance, loss of weight, increased sweating, increased bowel frequency and tachycardia. On GPE, there might be proptosis of eyes and tremors in the hands.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 19
Correct
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In diabetes, what is the most common finding on renal biopsy?
Your Answer: Glomerulosclerosis
Explanation:Glomerulosclerosis is the scarring and hardening of the glomeruli known as diabetic glomerulosclerosis occurring in long-standing diabetes.
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This question is part of the following fields:
- Renal System
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Question 20
Correct
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You are asked to fill the first part of a cremation form. Which of the following would need to be removed prior to cremation?
Your Answer: Pacemaker
Explanation:Pacemakers have small electrical parts installed in them that can explode when exposed to extreme heat and pressure.
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This question is part of the following fields:
- Ethical & Legal
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Question 21
Incorrect
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A 21-year-old patient presents with multiple itchy wheals on his skin. The wheals are of all sizes and they are exacerbated by scratching. The symptoms started after a viral infection and can last up to an hour. What is the most likely diagnosis?
Your Answer: Atopic eczema
Correct Answer: Urticaria
Explanation:Urticaria is a group of disorders that share a distinct skin reaction pattern, namely the occurrence of itchy wheals anywhere on the skin. Wheals are short-lived elevated erythematous lesions ranging from a few millimetres to several centimetres in diameter and can become confluent. The itching can be prickling or burning and is usually worse in the evening or night time. Triggering of urticaria by infections has been discussed for many years but the exact role and pathogenesis of mast cell activation by infectious processes is unclear.
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This question is part of the following fields:
- The Skin
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Question 22
Correct
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A 28-year-old male complained of the following: nausea, vertigo, vomiting for longer than 30 minutes, tinnitus, and hearing loss in his left ear. Which of the following treatment options is most appropriate for this patient?
Your Answer: Cyclazine (1st line)
Explanation:Cyclizine and prochlorperazine are both used for the treatment of Meniere’s disease.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 23
Correct
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A 21-year-old patient is referred to the tertiary neurology clinic because of a possible diagnosis of Juvenile Parkinson's disease. His symptoms began predominantly with dystonia affecting the lower limbs, but he now has more classical signs of older onset Parkinson's including tremor, bradykinesia, and rigidity.
You map out his family tree and understand that his sister developed Parkinson's at the age of 16 but that his parents do not have signs of Parkinson's.
Which of the following is the most likely mode of inheritance?Your Answer: Autosomal recessive
Explanation:Juvenile Onset Parkinson’s is an autosomal recessive condition that usually presents in late childhood to early adulthood, initially with gait disorders caused by lower limb dystonia that later develops to the more classical signs Parkinson’s.
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This question is part of the following fields:
- Nervous System
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Question 24
Correct
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A 63-year-old man presents with painless jaundice and weight loss over the last few months. He is a heavy smoker and has a past medical history of COPD. On examination his abdomen is soft and non tender and he is clearly icteric.
His bloods reveal deranged LFTs with an alkaline phosphates of 240 and a bilirubin of 92, ALT and AST are both around 200. An ultrasound of his abdomen is performed and shows both intra and extrahepatic bowel duct dilatation within the liver.
What's the first line investigation of his case?Your Answer: MRCP
Explanation:When you hear painless jaundice and weight loss in the same sentence, the first thing you should think is cancer. Likely cholangiocarcinoma here or some other biliary tract obstructing cancer. The first line imaging for this would be MRCP because you’re looking for obstruction– the dilatation of the intra and extrahepatic ducts suggests this. This is less invasive than an ERCP or a liver biopsy. CT C/A/P will likely be needed for staging later but it is asking for the initial test.
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This question is part of the following fields:
- Hepatobiliary System
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Question 25
Incorrect
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Which of the following is suggestive of co-existence of mitral regurgitation and mitral stenosis?
Your Answer: Localised tapping apex beat
Correct Answer: Displaced apex beat
Explanation:Apex beat displacement is caused by mitral regurgitation and because it is not found in mitral stenosis, it is suggestive of mixed mitral disease. The other given responses occur in mitral stenosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 26
Correct
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A 68-year-old woman with contralateral hemisensory loss presents with severe burning pain in this area. In which of the following areas has arterial occlusion most probably occurred?
Your Answer: Thalamogeniculate artery
Explanation:The woman’s clinical evolution suggests that there was a thalamic stroke in the contralateral hemisphere. The artery most likely affected is the thalamogeniculate artery. Sensory loss is usually unilateral and presents at the opposite side of the brain lesion. This kind of stroke can result in severe burning pain which is responsive to tricyclics.
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This question is part of the following fields:
- Nervous System
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Question 27
Incorrect
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A 60-year old male presented to the OPD with a complaint of a rusty-coloured sputum along with a cough for 3 days. His has a history of smoking for 40 years, and a history of significant weight loss. His chest X-ray revealed solid nodules in both lungs and bilateral hilar lymphadenopathy. Out of the following, which one is the most appropriate investigation?
Your Answer: CT
Correct Answer: LN biopsy
Explanation:The patient’s age, a history of long-term smoking, and bilateral hilar lymphadenopathy are strong indications of malignancy. Lymph node biopsy would be essential in order to check the degree of metastasis in the mediastinal lymph nodes.
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This question is part of the following fields:
- Respiratory System
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Question 28
Correct
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In an emergency bowel procedure, which among these antibiotics are indicated during anaesthetic induction?
Your Answer: Metronidazole
Explanation:Antibiotic prophylaxis is utilized to avert infection and is based on the degree of contamination involved in the surgical procedure. Operations where the wound is contained with minimal risk of contamination, antibiotic prophylaxis is questionable. In this case there is a high risk of contamination.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 29
Correct
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A 79-year-old woman has a waddling gait. History reveals enuresis and change in behaviour. What is the most likely diagnosis?
Your Answer: Normal pressure hydrocephalus
Explanation:The waddling gait and behaviour change are attributes of normal pressure hydrocephalus along with loss of bladder control which commonly happens with elder age.
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This question is part of the following fields:
- Geriatric Medicine
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Question 30
Correct
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A 43-year-old female presented with a 5 day history of a productive cough with rusty coloured sputum. Chest X-ray showed lobar consolidation on her left side. The most likely causative organism would be?
Your Answer: Streptococcus pneumoniae
Explanation:Streptococcus pneumonia is the chief causative organism for lobar pneumonia in this age group patients. Typically patients present with rusty coloured sputum and a cough. Pneumocystis jiroveci is responsible for causing pneumocystis pneumonia among immunocompromised patients.
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This question is part of the following fields:
- Infectious Diseases
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SESSION STATS - PERFORMANCE PER SPECIALTY
